The translational activator GCN3 functions downstream from GCN1 and GCN2 in the regulatory pathway that couples GCN4 expression to amino acid availability in Saccharomyces cerevisiae.
The GCN4 protein of S. cerevisiae is a transcriptional activator of amino acid biosynthetic genes which are subject to general amino acid control. GCN3, a positive regulator required for increased GCN4 expression in amino acid-starved cells, is thought to function by antagonism of one or more negative regulators encoded by GCD genes. We isolated gcn3c alleles that lead to constitutively derepressed expression of GCN4 and amino acid biosynthetic genes under its control. These mutations map in the protein-coding sequences and, with only one exception, do not increase the steady-state level of GCN3 protein. All of the gcn3c alleles lead to derepression of genes under the general control in the absence of GCN1 and GCN2, two other positive regulators of GCN4 expression. This finding suggests that GCN3 functions downstream from GCN1 and GCN2 in the general control pathway. In accord with this idea, constitutively derepressing alleles of GCN2 are greatly dependent on GCN3 for their derepressed phenotype. The gcn3c alleles that are least dependent on GCN1 and GCN2 for derepression cause slow-growth under nonstarvation conditions. In addition, all of the gcn3c alleles are less effective than wild-type GCN3 in overcoming the temperature-sensitive lethality associated with certain mutations in the negative regulator GCD2. These results suggest that activation of GCN3 positive regulatory function by the gcn3c mutations involves constitutive antagonism of GCD2 function, leading to reduced growth rates and derepression of GCN4 expression in the absence of amino acid starvation.


Evaluation of the influence of the addition of biodegradable polymer matrices in the formulation of self-curing polymer systems for biomedical purposes.
The solid phase of self-curing formulations of poly(methyl methacrylate) was modified by different biodegradable polymer matrices, such as poly(l-lactic acid), poly(beta-hydroxybutyrate) and thermoplastic starches (TPSs). The aim of this modification was the acquisition of a short- to medium-term drug delivery system to release bisphosphonates for hard tissue treatment. Different physico-chemical characterization techniques were used in order to determine the influence of these matrices and their mechanical capacity, in vitro behaviour, curing parameters, residual monomer content and surface topography for the preparation of the self-curing formulations. The incorporation of the polyesters did not induce an increase in water uptake capacity of the system due to their apolar aliphatic character. On the other hand, TPSs exhibited values of water absorption up to 15.3%, related with their hydrophilic chemical structure, dependent on the commercial formulation and the particle size distribution of the powder. The modifications of the solid phase led in all cases to a decrease in the mechanical behaviour of the material, although the formulations modified with TPS were in the range of accepted values according to standard specifications. The immersion of TPS formulations in a simulated physiological environment (phosphate buffer solution, pH 7.4, 37 degrees C) conducted to a surface porosity related with release of plasticizers of the domains of the biodegradable component of the formulation. Finally drug release capacity was studied by loading the material with Ibandronate, observing high dependence with the kind of TPS added, as well as its particle size.


Deep Optic Nerve Head Morphology Is Associated With Pattern of Glaucomatous Visual Field Defect in Open-Angle Glaucoma.
We investigated the relationship between visual field (VF) defect pattern and deep optic nerve head (ONH) morphology in open angle glaucoma (OAG) eyes using spectral-domain optical coherence tomography (SD-OCT). Of 278 OAG eyes, 169 with and 55 without externally oblique border tissue (EOBT) were included in the final analysis. Enhance depth imaging SD-OCT was used to measure the deep ONH parameters, such as EOBT length, ONH tilt angle, and optic canal (OC) obliqueness. The extents and locations of the maximum deep ONH parameters were explored according to VF pattern in OAG eyes. OAG eyes with EOBT showed longer axial length (AL; 25.6 vs. 24.4 mm; P < 0.001) and greater superior VF defects (67.5% vs. 49.1%; P = 0.02) compared to OAG eyes without EOBT. Multivariate logistic regression analysis revealed that relatively inferior location of maximum deep ONH parameters was associated with superior hemifield defects dominant in OAG (P < 0.001 in all parameters). In addition, the locations of maximum deep ONH parameters were consistent with dominant VF defect locations in OAG eyes with AL < 24.5 mm. The presence of paracentral scotoma in OAG was associated with worse mean deviation (MD) and relatively inferior location of deep ONH parameters. The locations of maximum deep ONH parameters were associated with the location of dominant VF defects and presence of paracentral scotoma in OAG eyes.


Proximal femoral replacement in patients with non-neoplastic conditions.
Numerous factors may give rise to the loss of femoral bone stock that can be encountered in revision hip arthroplasty. Proximal femoral replacement is an option for the treatment of severe proximal femoral bone loss. In this study, we sought to determine the outcome of reconstructive surgery with the use of a modular proximal femoral replacement (a so-called megaprosthesis) in patients with proximal femoral bone loss due to non-neoplastic conditions. A review of computerized databases from two institutions identified forty-eight patients with a mean age of 73.8 years who had undergone the placement of a modular megaprosthesis with or without bone-grafting. The indication for proximal femoral replacement was a periprosthetic fracture in twenty patients, reimplantation because of a deep infection in thirteen, a failed arthroplasty in thirteen, nonunion of an intertrochanteric fracture in one, and radiation-induced osteonecrosis with a subtrochanteric fracture in one. Three patients died before the minimum two-year follow-up interval had elapsed, and two additional patients were lost to follow-up. The mean duration of follow-up for the remaining study group of forty-three patients was 36.5 months. At the time of follow-up, there was a significant improvement in function as measured with the Harris hip score (p < 0.05). The proximal femoral replacement achieved an excellent or good functional outcome in twenty-two of the forty-three hips. The functional outcome was found to be fair in ten hips and poor in the remaining eleven. Ten patients required a reoperation or revision because of at least one complication. With revision used as the end point, the survivorship of the implant was 87% at one year and 73% at five years. Patients with severely compromised bone stock in whom the use of a conventional prosthesis is precluded because of an inability to achieve adequate fixation may be candidates for proximal femoral replacement. Our short-term results suggest that this is a viable salvage procedure for these patients.


Identification of potential pathway mediation targets in Toll-like receptor signaling.
Recent advances in reconstruction and analytical methods for signaling networks have spurred the development of large-scale models that incorporate fully functional and biologically relevant features. An extended reconstruction of the human Toll-like receptor signaling network is presented herein. This reconstruction contains an extensive complement of kinases, phosphatases, and other associated proteins that mediate the signaling cascade along with a delineation of their associated chemical reactions. A computational framework based on the methods of large-scale convex analysis was developed and applied to this network to characterize input-output relationships. The input-output relationships enabled significant modularization of the network into ten pathways. The analysis identified potential candidates for inhibitory mediation of TLR signaling with respect to their specificity and potency. Subsequently, we were able to identify eight novel inhibition targets through constraint-based modeling methods. The results of this study are expected to yield meaningful avenues for further research in the task of mediating the Toll-like receptor signaling network and its effects.


Decreased computed tomographic lung density during exacerbation of asthma.
Recently, it was shown that both mean lung density (MLD) and the relative lung area with an attenuation of <-950 HU (RA950) are related to severity of asthma in nonsmoking asthmatics. The aim of the present study was to examine whether reduced computed tomography (CT) lung density during exacerbation could change after treatment. A cross-sectional study was performed to compare CT lung density in 30 stable asthmatics, 30 unstable asthmatics and 25 control subjects. In order to investigate longitudinally the effect of treatment on decreased CT lung density, 17 asthmatics with an exacerbation were followed at the initiation of treatment and 2 months after relief. The MLD was significantly lower and the RA950 significantly higher in unstable asthmatics than in controls and stable asthmatics. Both MLD and RA950 changed significantly with administration of systemic glucocorticoid therapy. The changes in forced expiratory volume in one second correlated significantly with those in both MLD and RA950. The changes in residual volume also correlated significantly with those in both MLD and RA950. It was concluded that decreased computed tomographic lung density during an asthma exacerbation is at least partially reversible, and changes in mean lung density and the relative lung area with a radiation attenuation of <-950 HU are related to the change in forced expiratory volume in one second and residual volume.


Dual-Spectroscopy Platform for the Surveillance of Mars Mineralogy Using a Decisions Fusion Architecture on Simultaneous LIBS-Raman Data.
A single platform, integrated by a laser-induced breakdown spectroscopy detector and a Raman spectroscopy sensor, has been designed to remotely (5 m) and simultaneously register the elemental and molecular signatures of rocks under Martian surface conditions. From this information, new data fusion architecture at decisions level is proposed for the correct categorization of the rocks. The approach is based on a decision-making process from the sequential checking of the spectral features representing the cationic and anionic counterparts of the specimen. The scrutiny of the LIBS response by using a moving-window algorithm informs on the diversity of the elemental constituents. The output rate of emission lines allows projecting in a loop the elements as the cationic counterpart of the rock. In parallel, the Raman response of the unknown is compared with all the molecular counterparts of the hypothesized cation that are stored in a spectral library. The largest similarity rate unveils the final identity of the unknown. The identification capabilities of the architecture have been underscored through blind tests of 10 natural rocks with different origins. The great majority of forecasts have matched with the real identities of the inspected targets. The strength of this platform to simultaneously acquire the multielemental and the molecular information from a specimen by using the same laser events greatly enhances the "on-surface" missions for the surveillance of mineralogy.


Electron-crystallographic refinement of the structure of bacteriorhodopsin.
Using electron diffraction data corrected for diffuse scattering together with additional phase information from 30 new images of tilted specimens, an improved experimental density map has been calculated for bacteriorhodopsin. The atomic model has then been rebuilt into this new map with particular attention to the surface loops. All the residues from 7 to 227 as well as ten lipid molecules are now included, although a few amino acid residues in three of the six surface loops, about half of the lipid hydrophobic chains and all of the lipid head groups are disordered. The model has then been refined against the experimental diffraction amplitudes to an R-factor of 28% at 3.5 angstrom resolution with strict geometry (0.005 angstrom) bond length deviation) using the improvement of the "free" phase residual between calculated and experimental phases from images as an objective criterion of accuracy. For the refinement some new programs were developed to restrain the number of parameters, to be compatible with the limited resolution of our data. In the final refined model of the protein (2BRD), compared with earlier co-ordinates (1BRD), helix D has been moved towards the cytoplasm by almost 4 angstrom, and the overall accuracy of the co-ordinates of residues in the other six helices has been improved. As a result the positions of nearly all the important residues in bacteriorhodopsin are now well determined. In particular, the buried, protonated Asp115 is 7 angstrom from, and so not in contact with, the retinal and Met118 forms a cap on the pocket occupied by the beta-ionone ring. No clear density exists for the side-chain of Arg82, which forms a central part of the extracellular half-channel. The only arginine side-chain built into good density is that of Arg134 at the extracellular end of helix E, the others being disordered near one of the two surfaces. The interpretation of the end of helix F on the extracellular surface is now clearer; an extra loose helical turn has been built bringing the side-chain of Glu194 close to Arg134 to form a probable salt bridge. The model provides an improved framework for understanding the mechanism of the light-driven proton pumping. A number of cavities that could contain water molecules were found by searching the refined model, most of them above or below the Schiff base in the half-channels leading to the two surfaces. The ordered and disordered regions of the structure are described by the temperature factor distribution.


"String Hallucinations": Multimodal Tactile and Visual Hallucinations in Parkinson's Disease.
The aim of this work was to report on 7 patients presenting a distinctive form of multimodal (tactile and visual) hallucinations for which the term "string hallucinations" is proposed. Having observed a patient interacting with imaginary strips of skin in his hands at our movement disorders unit, we prospectively studied PD patients and caregivers over a 6-month period using a semistructured interview addressed to this particular phenomenon. Demographic characteristics as well as cognitive and motor function were assessed. A total of 7 of 164 PD patients (4.3%) observed during the study period had string hallucinations. One patient was cognitively intact and the other 6 had some degree of cognitive impairment. Common to the phenomenology of the hallucinations was the unpleasant feeling and vision of threads emerging from the subjects' hands. Patients interacted with these "threads," trying to remove them from their hands. Our study identifies a previously undescribed type of hallucinations in PD, characterized by a complex pattern of multimodal tactile and visual hallucinations.


Antioxidant activity and total phenolic and flavonoids content variations of leaves extracts of white Horehound (Marrubium vulgare Linné) from three geographical origins.
To elucidate the effect of the sampling location of Marrubium vulgare L. leaves on phenolic contents and antioxidant proprieties of flavonoids extracts. M. vulgare L. leaves were collected from three different geographical locations belonging to northwest Algeria: Tessala (mountain region), M'sila forest (coastal region), and Ain Skhouna (steppe region). The flavonoid extraction was achieved using organic solvents with different polarities (methanol, chloroform, ethyl acetate, and hexane). Folin-Ciocalteu colorimetric method was used for quantification of total phenolic contents, and aluminum chloride assay for quantification of total flavonoid contents. The antioxidant properties of flavonoids extract were studied by free l,l-diphenyl-2-picrylhydrazyl radical-scavenging technique. Total phenolic and flavonoids concentrations varied respectively between 40.7 and 160mg gallic acid equivalents/g and 27.4 and 66.3mg catechin equivalents/g. The DPPH free radical-scavenging activity shows that the antioxidant activity of the flavonoid extracts varied significantly (P<0.001) depending on the type of the organic solvent used, and the sampling location. The methanol, chloroform and ethyl acetate extracts exhibited the highest percentages of inhibition unlike to the aqueous and hexane extracts. These percentages are ranged from 54.8 to 98.8% at 1000μg/mL. In general, M'sila forest flavonoids extracts showed the highest free radical inhibition capacity; followed by those of Ain Skhouna and Tessala Mountain. The inhibitory concentration 50 (IC50) ranged from 33.7 to 774μg/mL and often exceeded those recorded by phenolic standards (ascorbic acid, gallic acid, caffeic acid, tannic acid and catechin). The phytochemical screening revealed the presence of some flavonoid classes, such as flavans and flavanols. The results suggested a potent antioxidant activity of M. vulgare flavonoids extracts, which may find its application in feature research for the food and the pharmacological industries.


Parent ratings of behavior in children with heavy prenatal alcohol exposure and IQ-matched controls.
Behavioral disturbances are well documented in children with heavy prenatal alcohol exposure. However, the degree to which these disturbances are related to factors other than alcohol, such as general intellectual functioning or socioeconomic status, is not known. Using the Child Behavior Checklist, parent-rated behaviors of children with histories of heavy prenatal alcohol exposure were compared with those of a control group matched by age, sex, socioeconomic status, ethnicity, and verbal IQ score. Using this same questionnaire, children with fetal alcohol syndrome were compared with children with heavy prenatal alcohol exposure that did not meet the criteria for fetal alcohol syndrome classification. Data were analyzed by multivariate analyses of covariance. In the comparison of children with and without a history of prenatal alcohol exposure, significant differences were found on the competence, problem, and summary scales (all p < 0.05). For the secondary comparison between the fetal alcohol syndrome and the heavy prenatal alcohol exposure groups, there were no significant differences on any of the scales (allp > 0.10). These results suggest that prenatal alcohol exposure results in the significant and profound impairment of parent-rated behaviors and that these deficits are not explained entirely by the presence or absence of facial dysmorphology, general intellectual functioning, or demographic factors.


Plant cytokinin signalling.
Cytokinin is an essential plant hormone that is involved in a wide range of plant growth and developmental processes which are controlled through its signalling pathway. Cytokinins are a class of molecules that are N(6)-substituted adenine derivatives, such as isopentenyl adenine, and trans- and cis-zeatin, which are common in most plants. The ability to perceive and respond to cytokinin occurs through a modified bacterial two-component pathway that functions via a multi-step phosphorelay. This cytokinin signalling process is a crucial part of almost all stages of plant life, from embryo patterning to apical meristem regulation, organ development and eventually senescence. The cytokinin signalling pathway involves the co-ordination of three types of proteins: histidine kinase receptors to perceive the signal, histidine phosphotransfer proteins to relay the signal, and response regulators to provide signal output. This pathway contains both positive and negative elements that function in a complex co-ordinated manner to control cytokinin-regulated plant responses. Although much is known about how this cytokinin signal is perceived and initially regulated, there are still many avenues that need to be explored before the role of cytokinin in the control of plant processes is fully understood.


Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial.
There is increasing evidence for the effectiveness of parental support programmes to promote healthy behaviours and prevent obesity in children, but only few studies have been conducted among groups with low socio-economic status. The aim of this study was to develop and evaluate the effectiveness of a parental support programme to promote healthy dietary and physical activity habits and to prevent overweight and obesity in six-year-old children in disadvantaged areas. A cluster-randomised controlled trial was carried out in disadvantaged areas in Stockholm. Participants were six-year-old children (n = 378) and their parents. Thirty-one school classes from 13 schools were randomly assigned to intervention (n = 16) and control groups (n = 15). The intervention lasted for 6 months and included: 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children. Physical activity was measured by accelerometry, dietary intake and screen time with a questionnaire, body weight and height were measured and BMI standard deviation score was calculated. Measurements were conducted at baseline, post-intervention and at 5months follow-up. Group effects were examined using Mixed-effect Regression analyses adjusted for sex, parental education and baseline values. Fidelity to all three intervention components was satisfactory. Significant intervention effects were found regarding consumption of unhealthy foods (p = 0.01) and unhealthy drinks (p = 0.01). At follow-up, the effect on intake of unhealthy foods was sustained for boys (p = 0.03). There was no intervention effect on physical activity. Further, the intervention had no apparent effect on BMI sds for the whole sample, but a significant difference between groups was detected among children who were obese at baseline (p = 0.03) which was not sustained at follow-up. The Healthy School Start study shows that it is possible to influence intake of unhealthy foods and drinks and weight development in obese children by providing individual parental support in a school context. However, the effects were short-lived. Therefore, the programme needs to be prolonged and/or intensified in order to obtain stronger and sustainable effects. This study is an important contribution to the further development of evidence-based parental support programmes to prevent overweight and obesity in children in disadvantaged areas.


Effects of thrust amplitude and duration of high-velocity, low-amplitude spinal manipulation on lumbar muscle spindle responses to vertebral position and movement.
Mechanical characteristics of high-velocity, low-amplitude spinal manipulations (HVLA-SMs) can vary. Sustained changes in peripheral neuronal signaling due to altered load transmission to a sensory receptor's local mechanical environment are often considered a mechanism contributing to the therapeutic effects of spinal manipulation. The purpose of this study was to determine whether variation in an HVLA-SM's thrust amplitude and duration alters the neural responsiveness of lumbar muscle spindles to either vertebral movement or position. Anesthetized cats (n = 112) received L6 HVLA-SMs delivered to the spinous process. Cats were divided into 6 cohorts depending upon the peak thrust force (25%, 55%, 85% body weight) or thrust displacement (1, 2, 3 mm) they received. Cats in each cohort received 8 thrust durations (0-250 milliseconds). Afferent discharge from 112 spindles was recorded in response to ramp and hold vertebral movement before and after the manipulation. Changes in mean instantaneous frequency (∆MIF) during the baseline period preceding the ramps (∆MIFresting), during ramp movement (∆MIFmovement), and with the vertebra held in the new position (∆MIFposition) were compared. Thrust duration had a small but statistically significant effect on ∆MIFresting at all 6 thrust amplitudes compared with control (0-millisecond thrust duration). The lowest amplitude thrust displacement (1 mm) increased ∆MIFresting at all thrust durations. For all the other thrust displacements and forces, the direction of change in ∆MIFresting was not consistent, and the pattern of change was not systematically related to thrust duration. Regardless of thrust force, displacement, or duration, ∆MIFmovement and ∆MIFposition were not significantly different from control. Relatively low-amplitude thrust displacements applied during an HVLA-SM produced sustained increases in the resting discharge of paraspinal muscle spindles regardless of the duration over which the thrust was applied. However, regardless of the HVLA-SM's thrust amplitude or duration, the responsiveness of paraspinal muscle spindles to vertebral movement and to a new vertebral position was not affected.


Excellent outcomes for adults who experienced early standardized treadmill training during acute phase of recovery from stroke: a case series.
To describe gait outcomes, including assistive device use and incidence of falls, in a group of adults post stroke who received early standardized treadmill training (ESTT) in the acute phase of rehabilitation. A case series of 18 individuals post stroke with varied lesion size, location, and comorbidities. Inpatient rehabilitation unit. Daily 30-minute sessions of ESTT initiated before overground training in the acute rehabilitation period. Three-dimensional gait analysis, 6-minute walk test (6MWT), assistive device inventory, and fall history. Gait analysis revealed better temporal and spatial symmetry than have been previously documented. Twelve participants walked at speeds of greater than 0.80 m/s and 10 walked without the use of an assistive device or orthoses. Mean 6MWT distance was 322.42 m (±114.33). Thirteen participants (72%) reported no falls over a 6-month period. These outcomes far surpass the current data reported in the literature for this patient population and were achieved by the application of an intervention that was feasible in the acute rehabilitation setting.


[Multi-slice spiral CT scan with lower dose for preoperative evaluation: living renal donor kidney morphology and the quantification of unilateral glomerular filtration rate].
To explore the feasibility of multi-slice spiral computed tomography (CT) with a lower dose as one-off examination for the preoperative morphology evaluation and the quantification of unilateral renal glomerular filtration rate of living renal donors. A total of 36 living renal donors at our hospital from May 2008 to June 2009 were examined by 64-slice spiral CT and single photon emission computed tomography (SPECT). Living renal donors were examined with a plain scan and three-phase enhancement CT scan. Also there were two inserted dynamic scans, one after the injection of contrast agent and the other between cortex and parenchymal phases. Image reconstructions were performed to observe renal parenchyma, renal vessels and collecting system. Comparisons were made with intra-operative findings. And the known Patlak equation was used simultaneously. The glomerular filtration rate (GFR) in a single kidney was calculated on CT and SPECT respectively. The GFRs of two groups were analyzed to investigate the Pearson correlation and simple linear regression between them. Twenty of 36 renal living donor kidneys underwent the operation, variations of morphology detected by CT were all corresponded with the operation. The GFR values estimated from CT were (42.4 ± 8.9) ml/min (left) and 43.2 ± 8.4) ml/min (right). While GFR of SPECT 47.4 ± 9.3) ml/min (left) and 48.2 ± 8.5) ml/min (right). Linear trend was found between the GFRs of CT and SPECT. Pearson's product-moment correlation coefficient r = 0.753 (left) (P < 0.01), r = 0.709 (right) (P < 0.01). These values indicated that the GFR from CT was positively correlated with the GFR from SPECT. During the preoperative evaluation, multi-slice spiral CT may provide both anatomic information and the GFR of living renal donors.


Support for a chromosome 18p locus conferring susceptibility to functional psychoses in families with schizophrenia, by association and linkage analysis.
The action of antipsychotic drugs on dopamine receptors suggests that dopaminergic signal transmission may play a role in the development of schizophrenia. We tested eight candidate genes (coding for dopamine receptors, the dopamine transporter, and G-proteins) in 59 families from Germany and Israel, for association. A P value of .00055 (.0044 when corrected for the no. of markers tested) was obtained for the intronic CA-repeat marker G-olfalpha on chromosome 18p. The value decreased to .000088 (.0007) when nine sibs with recurrent unipolar depressive disorder were included. Linkage analysis using SSLP markers densely spaced around G-olfalpha yielded a maximum two-point LOD score of 3.1 for a marker 0.5 cM distal to G-olfalpha. Multipoint analysis under the assumption of heterogeneity supported this linkage-whether the affected pheotype was defined narrowly or broadly-as did nonparametric linkage (NPL). In 12 families with exclusively maternal transmission of the disease, the NPL value also supported linkage to this marker. In order to test for association/linkage disequilibrium in the presence of linkage, the sample was restricted to independent offspring. When this sample was combined with 65 additional simplex families (each of them comprising one schizophrenic offspring and his or her parents), the 124-bp allele of G-olfalpha was transmitted 47 times and was not transmitted 21 times (P=.009). These results suggest the existence, on chromosome 18p, of a potential susceptibility locus for functional psychoses.


Cystamine metabolism and brain transport properties: clinical implications for neurodegenerative diseases.
Cystamine has shown significant neuroprotective properties in preclinical studies of Parkinson's disease (PD) and Huntington's disease (HD). Cysteamine, its FDA-approved reduced form, is scheduled to be tested for clinical efficacy in HD patients. Here, we studied the key cystamine metabolites, namely cysteamine, hypotaurine and taurine, as well as cysteine, in order to identify which one is more distinctively responsible for the neuroprotective action of cystamine. After a single administration of cystamine (10, 50 or 200 mg/kg), naïve mice were perfused with phosphate-buffered saline (PBS) at 1, 3, 12, 24 or 48 h post-injection and brain and plasma samples were analyzed by two distinct HPLC methods. Although plasma levels remained under the detection threshold, significant increases in cysteamine brain levels were detected with the 50 and 200 mg/kg doses in mice perfused 1 and 3 h following cystamine injection. To further assess cysteamine as the candidate molecule for pre-clinical and clinical trials in PD, we evaluated its capacity to cross the blood brain barrier. Using an in situ cerebral perfusion technique, we determined that the brain transport coefficient (Clup) of cysteamine (259 μM) was 0.15 ± 0.02 μL/g/s and was increased up to 0.34 ± 0.07 μL/g/s when co-perfused in the presence of cysteine. Taken together, these results strongly suggest that cysteamine is the neuroactive metabolite of cystamine and may further support its therapeutic use in neurodegenerative diseases, particularly in HD and PD.


Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission.
Hyperlactatemia upon admission is a documented risk factor for mortality in critically ill adult patients. However, the predictive significance of a single lactate measurement at admission for mortality in the general population of critically ill children remains uncertain. This study evaluated the predictive value of blood lactate levels at admission and determined the cut-off values for predicting in-hospital mortality in the critically ill pediatric population. We enrolled 1109 critically ill children who were admitted to a pediatric intensive care unit between July 2008 and December 2010. Arterial blood samples were collected in the first 2 hours after admission, and the lactate levels were determined. The Pediatric Risk of Mortality III (PRISM III) scores were calculated during the first 24 hours after admission. Of the 1109 children admitted, 115 (10.4%) died in the hospital. The median (interquartile range) blood lactate level in critically ill children was 3.2 mmol/l (2.2-4.8). Among the children, 859 (77.5%) had a lactate concentration >2.0 mmol/l. The blood lactate level upon admission was significantly associated with mortality (odds ratio [OR] = 1.38; 95% confidence interval [CI], 1.30-1.46; p <0.001), even after adjustment for age, gender, and illness severity assessed by PRISM III (OR = 1.27; p <0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07-1.29; p = 0.001), a high PRISM III score (OR = 1.15; 95% CI, 1.11-1.20; p <0.001), and a low serum albumin (OR =0.92; 95% CI, 0.88-0.96; p <0.001) were independent risk factors for mortality in critically ill children. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (p <0.001) for predicting mortality that was similar to that of PRISM III (AUC = 0.82; p <0.001). The p-value for a comparison of both AUCs was 0.318. Blood lactate displayed a sensitivity of 61% and a specificity of 86% in predicting mortality at the optimal cut-off value of 5.55 mmol/l, and the positive and negative likelihood ratios were 4.5 and 0.45, respectively. A high blood lactate level at admission is independently associated with and predictive of in-hospital mortality in the general population of critically ill children.


Improvement in precision grip force control with self-modulation of primary motor cortex during motor imagery.
Motor imagery (MI) has shown effectiveness in enhancing motor performance. This may be due to the common neural mechanisms underlying MI and motor execution (ME). The main region of the ME network, the primary motor cortex (M1), has been consistently linked to motor performance. However, the activation of M1 during motor imagery is controversial, which may account for inconsistent rehabilitation therapy outcomes using MI. Here, we examined the relationship between contralateral M1 (cM1) activation during MI and changes in sensorimotor performance. To aid cM1 activity modulation during MI, we used real-time fMRI neurofeedback-guided MI based on cM1 hand area blood oxygen level dependent (BOLD) signal in healthy subjects, performing kinesthetic MI of pinching. We used multiple regression analysis to examine the correlation between cM1 BOLD signal and changes in motor performance during an isometric pinching task of those subjects who were able to activate cM1 during motor imagery. Activities in premotor and parietal regions were used as covariates. We found that cM1 activity was positively correlated to improvements in accuracy as well as overall performance improvements, whereas other regions in the sensorimotor network were not. The association between cM1 activation during MI with performance changes indicates that subjects with stronger cM1 activation during MI may benefit more from MI training, with implications toward targeted neurotherapy.


TCR/CD3 coupling to Fas-based cytotoxicity.
We studied the coupling of the TCR/CD3 complex to a T cell effector function, namely Fas-based T-cell-mediated cytotoxicity. Encounter or re-encounter with antigen was mimicked by treating 5 d mixed lymphocyte culture cells or T cell hybridomas with anti-CD3 antibody. This TCR/CD3 engagement induced swift expression of Fas-based cytotoxicity in these cells. Induction of Fas-based cytotoxicity was Ca(2+)-dependent, while its execution was not; induction was sensitive to macromolecular synthesis inhibitors, in line with a demonstrable increase of the Fas ligand (Fas-L) message. We also used T cell hybridomas transfected with various constructs to dissect the involvement of distinct components of the TCR/CD3 complex. The cytoplasmic domain of the CD3 zeta chain was able to transduce by itself a signal leading to Fas-L expression, unless there were mutations in its activation receptor homology sequence 1 (ARH-1) motifs. On the one hand, these findings are relevant to signal transduction pathways coupled to the TCR/CD3, and on the other hand, to the involvement of Fas-based T cell-mediated cytotoxicity in various physiological and possibly pathophysiological situations.


agr function in clinical Staphylococcus aureus isolates.
The accessory gene regulator (agr) of Staphylococcus aureus is a global regulator of the staphylococcal virulon, which includes secreted virulence factors and surface proteins. The agr locus is important for virulence in a variety of animal models of infection, and has been assumed by inference to have a major role in human infection. Although most human clinical S. aureus isolates are agr(+), there have been several reports of agr-defective mutants isolated from infected patients. Since it is well known that the agr locus is genetically labile in vitro, we have addressed the question of whether the reported agr-defective mutants were involved in the infection or could have arisen during post-isolation handling. We obtained a series of new staphylococcal isolates from local clinical infections and handled these with special care to avoid post-isolation mutations. Among these isolates, we found a number of strains with non-haemolytic phenotypes owing to mutations in the agr locus, and others with mutations elsewhere. We have also obtained isolates in which the population was continuously heterogeneous with respect to agr functionality, with agr(+) and agr(-) variants having otherwise indistinguishable chromosomal backgrounds. This finding suggested that the agr(-) variants arose by mutation during the course of the infection. Our results indicate that while most clinical isolates are haemolytic and agr(+), non-haemolytic and agr(-) strains are found in S. aureus infections, and that agr(+) and agr(-) variants may have a cooperative interaction in certain types of infections.


Evaluation of tortuous vertebral arteries before cervical spine surgery: illustrative case.
Cervical spine surgery sometimes necessitates complex ventral/dorsal approaches or osteotomies that place the vertebral artery (VA) at risk of inadvertent injury. Tortuosity of the VA poses increased risk of vessel injury during anterior decompression or placement of posterior instrumentation. In this report, the authors describe a patient with degenerative cervical spondylotic myelopathy and focal kyphotic deformity requiring corrective surgery via a combined ventral/dorsal approach. Computed tomography (CT) and CT angiography (CTA) of the spine identified a left medially enlarged C4 transverse foramen and tortuous VA V2 segment forming a potentially dangerous medial loop into the vertebral body, respectively. The patient's presentation and management are described. The course of the VA is variable, and a tortuous VA with significant medial or lateral displacement may be dangerous during ventral and dorsal approaches to the cervical spine. CTA of the cervical spine is warranted in cases in which atlantoaxial fixation is needed or suspicious transverse foramen morphology is identified to understand the course of the VA and identify anatomical variations that would put the VA at risk during cervical spine surgery.


Early Induction of Human Regulatory Dermal Antigen Presenting Cells by Skin-Penetrating Schistosoma Mansoni Cercariae.
Following initial invasion of Schistosoma mansoni cercariae, schistosomula reside in the skin for several days during which they can interact with the dermal immune system. While murine experiments have indicated that exposure to radiation-attenuated (RA) cercariae can generate protective immunity which is initiated in the skin stage, contrasting non-attenuated cercariae, such data is missing for the human model. Since murine skin does not form a reliable marker for immune responses in human skin, we used human skin explants to study the interaction with non-attenuated and RA cercariae with dermal innate antigen presenting cells (APCs) and the subsequent immunological responses. We exposed human skin explants to cercariae and visualized their invasion in real time (initial 30 min) using novel imaging technologies. Subsequently, we studied dermal immune responses and found an enhanced production of regulatory cytokine interleukin (IL)-10, pro-inflammatory cytokine IL-6 and macrophage inflammatory protein (MIP)-1α within 3 days of exposure. Analysis of dermal dendritic cells (DDCs) for their phenotype revealed an increased expression of immune modulators programmed death ligand (PD-L) 1 and 2, and increased IL-10 production. Ex vivo primed DDCs suppress Th1 polarization of naïve T-cells and increase T-cell IL-10 production, indicating their regulatory potential. These immune responses were absent or decreased after exposure to RA parasites. Using transwells, we show that direct contact between APCs and cercariae is required to induce their regulatory phenotype. To the best of our knowledge this is the first study that attempts to provide insight in the human dermal S. mansoni cercariae invasion and subsequent immune responses comparing non-attenuated with RA parasites. We reveal that cercariae induce a predominantly regulatory immune response whereas RA cercariae fail to achieve this. This initial understanding of the dermal immune suppressive capacity of S. mansoni cercariae in humans provides a first step toward the development of an effective schistosome vaccine.


Dose-related adverse events in South African patients prescribed clofazimine for drug-resistant tuberculosis.
Optimal drug levels and minimal toxicity are critical factors in improving treatment outcomes for patients prescribed new and repurposed medicine for drug-resistant (DR) tuberculosis (TB). The optimal dose and dose-related safety of clofazimine (CFZ), a repurposed medicine for DR TB, in the South African (SA) population are unknown. To report on dose-related adverse events in patients receiving CFZ plus a background regimen for DR TB. In a retrospective review of patient folders from 2012 to 2014, adverse events documented for patients receiving high- (≥200 mg) and low-dose (100 mg) CFZ in a centralised DR TB hospital in KwaZulu-Natal Province, SA, were investigated for an association between dose-weight interactions and adverse events. Of 600 patients included, 78.7% (n=472) weighed ≥50 kg. Of these, 17.4% (n=82) received 100 mg CFZ and 82.6% (n=390) received >200 mg. Of 128 patients (21.3%) who weighed <50 kg, 68.0% (n=87) received 100 mg CFZ and 32.0% (n=41) received ≥200 mg. Of 463 patients (77.2%) who were HIV-positive, 94.0% were on antiretrovirals. There was no difference between the dose-weight cohorts in the background regimen given in addition to high- or low-dose CFZ. The frequency and types of adverse events observed were similar to the published literature. When analysed per dose-weight cohort, patients weighing <50 kg and receiving high-dose CFZ (≥200 mg) had a 2.6 times higher risk of any adverse event (adjusted odds ratio (aOR) 2.57; 95% confidence interval (CI) 1.02 - 6.05; p=0.05: reference category <50 kg and 100 mg). Patients weighing <50 kg and receiving high-dose CFZ had a 3.3 times higher risk of gastrointestinal adverse events than patients weighing <50 kg and receiving 100 mg CFZ (aOR 3.30; 95% CI 1.51 - 7.19; p=0.003). A high risk of chest pain was observed in patients receiving high- and low-dose CFZ, irrespective of weight. Patients weighing <50 kg receiving high-dose CFZ had a slightly higher risk of adverse events related to the skin (aOR 1.2; 95% CI 0.55 - 2.62; p=0.7) There were no documented reports of the CFZ dose being reduced or the drug being stopped due to adverse events in the sample population. There is an association between dose-weight interaction and adverse events. The odds of any adverse event occurring were higher when low-weight patients (<50 kg) received high-dose CFZ (≥200 mg). Gastrointestinal and skin-related adverse events were more common when high-dose CFZ was used in patients weighing <50 kg. Chest pain was reported in patients receiving high- and low-dose CFZ, irrespective of weight, and may be a symptom of cardiac toxicity. Plasma concentrations of CFZ may be affected by drug-drug interactions, so active drug safety monitoring including electrocardiograms is recommended routinely when CFZ is part of the regimen.


Hypoglycemia in diabetes.
Iatrogenic hypoglycemia causes recurrent morbidity in most people with type 1 diabetes and many with type 2 diabetes, and it is sometimes fatal. The barrier of hypoglycemia generally precludes maintenance of euglycemia over a lifetime of diabetes and thus precludes full realization of euglycemia's long-term benefits. While the clinical presentation is often characteristic, particularly for the experienced individual with diabetes, the neurogenic and neuroglycopenic symptoms of hypoglycemia are nonspecific and relatively insensitive; therefore, many episodes are not recognized. Hypoglycemia can result from exogenous or endogenous insulin excess alone. However, iatrogenic hypoglycemia is typically the result of the interplay of absolute or relative insulin excess and compromised glucose counterregulation in type 1 and advanced type 2 diabetes. Decrements in insulin, increments in glucagon, and, absent the latter, increments in epinephrine stand high in the hierarchy of redundant glucose counterregulatory factors that normally prevent or rapidly correct hypoglycemia. In insulin-deficient diabetes (exogenous) insulin levels do not decrease as glucose levels fall, and the combination of deficient glucagon and epinephrine responses causes defective glucose counterregulation. Reduced sympathoadrenal responses cause hypoglycemia unawareness. The concept of hypoglycemia-associated autonomic failure in diabetes posits that recent antecedent hypoglycemia causes both defective glucose counterregulation and hypoglycemia unawareness. By shifting glycemic thresholds for the sympathoadrenal (including epinephrine) and the resulting neurogenic responses to lower plasma glucose concentrations, antecedent hypoglycemia leads to a vicious cycle of recurrent hypoglycemia and further impairment of glucose counterregulation. Thus, short-term avoidance of hypoglycemia reverses hypoglycemia unawareness in most affected patients. The clinical approach to minimizing hypoglycemia while improving glycemic control includes 1) addressing the issue, 2) applying the principles of aggressive glycemic therapy, including flexible and individualized drug regimens, and 3) considering the risk factors for iatrogenic hypoglycemia. The latter include factors that result in absolute or relative insulin excess: drug dose, timing, and type; patterns of food ingestion and exercise; interactions with alcohol and other drugs; and altered sensitivity to or clearance of insulin. They also include factors that are clinical surrogates of compromised glucose counterregulation: endogenous insulin deficiency; history of severe hypoglycemia, hypoglycemia unawareness, or both; and aggressive glycemic therapy per se, as evidenced by lower HbA(1c) levels, lower glycemic goals, or both. In a patient with hypoglycemia unawareness (which implies recurrent hypoglycemia) a 2- to 3-week period of scrupulous avoidance of hypoglycemia is advisable. Pending the prevention and cure of diabetes or the development of methods that provide glucose-regulated insulin replacement or secretion, we need to learn to replace insulin in a much more physiological fashion, to prevent, correct, or compensate for compromised glucose counterregulation, or both if we are to achieve near-euglycemia safely in most people with diabetes.


Genome-Wide Association Studies to Drug: Identifying Retinoic Acid Metabolism Blocking Agents to Suppress Mechanoflammation in Osteoarthritis.
Osteoarthritis (OA) is a highly prevalent debilitating joint disease for which there are currently no licensed disease-modifying treatments. The pathogenesis of OA is complex, involving genetic, mechanical, biochemical, and environmental factors. Cartilage injury, arguably the most important driving factor in OA development, is able to activate both protective and inflammatory pathways within the tissue. Recently, >100 genetic risk variants for OA have been identified through Genome Wide Association Studies, which provide a powerful tool to validate existing putative disease pathways and discover new ones. Using such an approach, hypomorphic variants within the aldehyde dehydrogenase 1 family member A2 (ALDH1A2) gene were shown to be associated with increased risk of severe hand OA. ALDH1A2 encodes the enzyme that synthesizes all-trans retinoic acid (atRA), an intracellular signaling molecule. This review summarizes the influence of the genetic variants on expression and function of ALDH1A2 in OA cartilage, its role in the mechanical injury response of cartilage, and its potent anti-inflammatory effect after cartilage injury. In doing so it identifies atRA metabolism-blocking agents as potential treatments for suppressing mechanoflammation in OA.


Hematological parameters and prevalence of anemia in white and British Indian vegetarians and nonvegetarians in the UK Biobank.
There may be differences in hematological parameters between meat-eaters and vegetarians. The aim of this study was to perform cross-sectional analyses of hematological parameters by diet group in a large cohort in the United Kingdom. A complete blood count was carried out in all UK Biobank participants at recruitment (2006-2010). We examined hemoglobin, red and white blood cell counts, and platelet counts and volume in regular meat eaters (>3 times/wk of red/processed meat consumption, n = 212,831), low meat eaters (n = 213,092), poultry eaters (n = 4815), fish eaters (n = 10,042), vegetarians (n = 6548), and vegans (n = 398) of white ethnicity and meat eaters (n = 3875) and vegetarians (n = 1362) of British Indian ethnicity. In both white and British Indian populations, compared with regular meat eaters (or meat eaters in Indians), the other diet groups had up to 3.7% lower age-adjusted hemoglobin concentrations (difference not significant in white vegan women) and were generally more likely to have anemia (e.g., 8.7% of regular meat eaters compared with 12.8% of vegetarians in white premenopausal women; P < 0.05 after Bonferroni correction). In the white population, compared with regular meat eaters, all other diet groups had lower age- and sex-adjusted total white cells, neutrophils, lymphocytes, monocytes, and eosinophils (P-heterogeneity < 0.001 for all), but basophil counts were similar across diet groups; in British Indians, there was no significant difference in any of the white blood cell counts by diet group. Compared with white regular meat eaters, the low meat eaters, poultry eaters, fish eaters, and vegans had significantly lower platelet counts and higher platelet volume, whereas vegetarians had higher counts and lower volume. Compared with British Indian meat eaters, vegetarians had higher platelet count and lower volume. In the UK Biobank, people with low or no red meat intake generally had lower hemoglobin concentrations and were slightly more likely to be anemic. The lower white blood cell counts observed in low and non-meat eaters, and differences in mean platelet counts and volume between diet groups, warrant further investigation. This observational study was registered at http://www.isrctn.com/ as ISRCTN10125697.


Comparison of variability in pork carcass composition and quality between barrows and gilts.
Pigs ( = 8,042) raised in 8 different barns representing 2 seasons (cold and hot) and 2 production focuses (lean growth and meat quality) were used to characterize variability of carcass composition and quality traits between barrows and gilts. Data were collected on 7,684 pigs at the abattoir. Carcass characteristics, subjective loin quality, and fresh ham face color (muscles) were measured on a targeted 100% of carcasses. Fresh belly characteristics, boneless loin weight, instrumental loin color, and ultimate loin pH measurements were collected from 50% of the carcasses each slaughter day. Adipose tissue iodine value (IV), 30-min loin pH, LM slice shear force, and fresh ham muscle characteristic measurements were recorded on 10% of carcasses each slaughter day. Data were analyzed using the MIXED procedure of SAS as a 1-way ANOVA in a randomized complete block design with 2 levels (barrows and gilts). Barn (block), marketing group, production focus, and season were random variables. A 2-variance model was fit using the REPEATED statement of the MIXED procedure, grouped by sex for analysis of least squares means. Homogeneity of variance was tested on raw data using Levene's test of the GLM procedure. Hot carcass weight of pigs (94.6 kg) in this study was similar to U.S. industry average HCW (93.1 kg). Therefore, these data are representative of typical U.S. pork carcasses. There was no difference ( ≥ 0.09) in variability of HCW or loin depth between barrow and gilt carcasses. Back fat depth and estimated carcass lean were more variable ( ≤ 0.0001) and IV was less variable ( = 0.05) in carcasses from barrows than in carcasses from gilts. Fresh belly weight and thickness were more variable ( ≤ 0.01) for bellies of barrows than bellies of gilts, but there was no difference in variability for belly length, width, or flop distance ( ≥ 0.06). Fresh loin subjective color was less variable ( < 0.01) and subjective marbling was more variable ( < 0.0001) in loins from barrows than in those from gilts, but there were no differences ( ≥ 0.08) in variability for any other loin traits or fresh ham traits. Overall, traits associated with carcass fatness, including back fat depth, belly thickness, and marbling, but not IV, were more variable in carcasses from barrows than in carcasses from gilts, whereas minimal differences in variability existed between carcasses of barrows and carcasses of gilts for traits associated with carcass muscling and lean quality.


Effect of dapagliflozin on urinary albumin excretion in patients with chronic kidney disease with and without type 2 diabetes: a prespecified analysis from the DAPA-CKD trial.
Reductions in albuminuria are associated with a subsequent lower risk of kidney failure in patients with chronic kidney disease. The SGLT2 inhibitor dapagliflozin significantly reduced albuminuria in patients with type 2 diabetes and normal or near-normal kidney function. Whether this effect persists in patients with chronic kidney disease with and without type 2 diabetes is unknown. We assessed the effects of dapagliflozin on albuminuria in patients with chronic kidney disease with and without type 2 diabetes in the dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trial. DAPA-CKD was a multicentre, double-blind, placebo-controlled, randomised trial done at 386 sites in 21 countries. Patients were eligible for the trial if they had chronic kidney disease, defined as an estimated glomerular filtration rate (eGFR) between 25 mL/min per 1·73 m2 and 75 mL/min per 1·73 m2 and a urinary albumin-to-creatinine ratio (UACR) between 200 mg/g and 5000 mg/g (22·6 to 565·6 mg/mmol). Participants were randomly assigned to dapagliflozin 10 mg (AstraZeneca; Gothenburg, Sweden) once daily or matching placebo, in accordance with the sequestered, fixed randomisation schedule, using balanced blocks to ensure an approximate 1:1 ratio. Change in albuminuria was a pre-specified exploratory outcome of DAPA-CKD. Regression in UACR stage, defined as a transition from macroalbuminuria (≥300 mg/g) to microalbuminuria or normoalbuminuria (<300 mg/g), and progression in UACR stage, defined as a transition from less than 3000 mg/g to 3000 mg/g or greater, were additional discrete endpoints. The trial is registered with ClinicalTrials.gov, NCT03036150. Between Feb 2, 2017, and April 3, 2020, 4304 patients were recruited and randomly assigned to either dapagliflozin (n=2152) or placebo (n=2152). Median UACR was 949 mg/g (IQR 477 to 1885). Overall, compared with placebo, dapagliflozin reduced geometric mean UACR by 29·3% (95% CI -33·1 to -25·2; p<0·0001); relative to placebo, treatment with dapagliflozin resulted in a geometric mean percentage change of -35·1% (95% CI -39·4 to -30·6; p<0·0001) in patients with type 2 diabetes and -14·8% (-22·9 to -5·9; p=0·0016) in patients without type 2 diabetes over the follow-up visits (pinteraction<0·0001) Among 3860 patients with UACR of 300 mg/g or greater at baseline, dapagliflozin increased the likelihood of regression in UACR stage (hazard ratio 1·81, 95% CI 1·60 to 2·05). Among 3820 patients with UACR less than 3000 mg/g at baseline, dapagliflozin decreased the risk of progression in UACR stage (0·41, 0·32 to 0·52). Larger reductions in UACR at day 14 during dapagliflozin treatment were significantly associated with attenuated eGFR decline during subsequent follow-up (β per log unit UACR change -3·06, 95% CI -5·20 to -0·90; p=0·0056). In patients with chronic kidney disease with and without type 2 diabetes, dapagliflozin significantly reduced albuminuria, with a larger relative reduction in patients with type 2 diabetes. The similar effects of dapagliflozin on clinical outcomes in patients with or without type 2 diabetes, but different effects on UACR, suggest that part of the protective effect of dapagliflozin in patients with chronic kidney disease might be mediated through pathways unrelated to reduction in albuminuria. AstraZeneca.


Moving to patient reported collection of race and ethnicity data: implementation and impact in ten hospitals.
The purpose of this paper is to examine the feasibility of collecting standardized, patient reported race and ethnicity (RE) data in hospitals, and to assess the impact on data quality and utility. Part of a larger evaluation that included a comprehensive assessment. Sites documented RE data collection procedures before and after program implementation. Primary data collected through qualitative interviewing with key respondents in ten hospitals to assess implementation. Nine hospitals provided RE data on the same patients before and after implementation new data collection procedures were implemented to assess impact. Implementation went smoothly in nine of ten hospitals and had substantial effects on the hospital staff awareness on the potential for disparities within their hospitals. New procedures had minimal impact on characterization of readmitted patients. This study demonstrated that it is feasible for staff in a diverse group of hospitals to implement systematic, internally standardized methods to collect self-reported RE data from patients. Although this study found little impact patients' demographic characterizations, other benefits included greater awareness of and attention to disparities, uncovering small pockets of minorities, and dramatically increased RE data use in quality improvement efforts.


A Comparison of Diarrheal Severity Scores in the MAL-ED Multisite Community-Based Cohort Study.
There is a lack of consensus on how to measure diarrheal severity. Within the context of a multisite, prospective cohort study, we evaluated the performance of a modified Vesikari score (MAL-ED), 2 previously published scores (Clark and CODA [a diarrheal severity score (Community DiarrheA) published by Lee et al]), and a modified definition of moderate-to-severe diarrhea (MSD) based on dysentery and health care worker diagnosed dehydration. Scores were built using maternally reported symptoms or fieldworker-reported clinical signs obtained during the first 7 days of a diarrheal episode. The association between these and the risk of hospitalization were tested using receiver operating characteristic analysis. Severity scores were also related to illness etiology, and the likelihood of the episode subsequently becoming prolonged or persistent. Of 10,159 episodes from 1681 children, 143 (4.0%) resulted in hospitalization. The area under the curve of each score as a predictor of hospitalization was 0.84 (95% confidence interval: 0.81, 0.87) (Clark), 0.85 (0.82, 0.88) (MAL-ED), and 0.87 (0.84, 0.89) (CODA). Severity was also associated with etiology and episode duration. Although families were more likely to seek care for severe diarrhea, approximately half of severe cases never reached the health system. Community-based diarrheal severity scores are predictive of relevant child health outcomes. Because they require no assumptions about health care access or utilization, they are useful in refining estimates of the burden of diarrheal disease, in estimating the effect of disease control interventions, and in triaging children for referral in low- and middle-income countries in which the rates of morbidity and mortality after diarrhea remain high.


Multi-element chemical analysis of printed circuit boards - challenges and pitfalls.
Printed circuit boards (PCB) are an essential component of electrical and electronic equipment (EEE) and account for roughly 5% of the mass of EEE. Knowledge about the chemical composition of PCB is crucial to enable an enhanced recycling, especially for elements considered critical regarding their economic importance and supply risk (e.g. precious metals or specialty metals such as tantalum, germanium, gallium). No standard reference methods exist for determining the chemical composition of PCB. Previously published element mass fractions cover a wide range and were produced with numerous methods for sample preparation, digestion, and measurement. This impedes comparability of PCB composition from different studies. To investigate sample- and element-specific effects of applied methods a PCB sample from desktop PC was analysed in two separate labs. One lab applied sample- and element-specific validated methods (aqua regia, HF, H2SO4 blend; ICP-OES, QQQ-ICP-MS), providing reference values, the other applied routine in-house methods (aqua regia; ICP-OES, ICP-MS) to assess the validity of in-house methods for chemical analysis of PCB. A t-test was used to identify elements depicting significant differences between validated and in-house methods. For base metals, in-house methods led to comparable results. For precious, specialty, and hazardous metals as well as REE investigated in this study, significant differences were detected. With respect to all results for in-house methods in this study, the combination of aqua regia and ICP-OES led to less significant differences than aqua regia and ICP-MS. The results show that sample- and element-specific quality assurance is crucial to prevent analytical bias.


What do we mean by web-based learning? A systematic review of the variability of interventions.
Educators often speak of web-based learning (WBL) as a single entity or a cluster of similar activities with homogeneous effects. Yet a recent systematic review demonstrated large heterogeneity among results from individual studies. Our purpose is to describe the variation in configurations, instructional methods and presentation formats in WBL. We systematically searched MEDLINE, EMBASE, ERIC, CINAHL and other databases (last search November 2008) for studies comparing a WBL intervention with no intervention or another educational activity. From eligible studies we abstracted information on course participants, topic, configuration and instructional methods. We summarised this information and then purposively selected and described several WBL interventions that illustrate specific technologies and design features. We identified 266 eligible studies. Nearly all courses (89%) used written text and most (55%) used multimedia. A total of 32% used online communication via e-mail, threaded discussion, chat or videoconferencing, and 9% implemented synchronous components. Overall, 24% blended web-based and non-computer-based instruction. Most web-based courses (77%) employed specific instructional methods, other than text alone, to enhance the learning process. The most common instructional methods (each used in nearly 50% of courses) were patient cases, self-assessment questions and feedback. We describe several studies to illustrate the range of instructional designs. Educators and researchers cannot treat WBL as a single entity. Many different configurations and instructional methods are available for WBL instructors. Researchers should study when to use specific WBL designs and how to use them effectively.


Effect of Diagnosed Sleep Disorders on Baseline Concussion Symptom, Cognitive, and Balance Assessments in Collegiate Athletes.
Symptoms, cognition, balance, and other domains are commonly assessed at baseline testing as part of comprehensive preseason evaluations among collegiate student-athletes. Although approximately 27% of college students have at least 1 sleep disorder, researchers have yet to examine the role of a preexisting sleep disorder on preinjury baseline performance. To compare athletes with and without a reported history of diagnosed sleep disorders on commonly used baseline concussion assessments. Cross-sectional study; Level of evidence, 3. A total of 666 National Collegiate Athletic Association student-athletes completed baseline measures including the Balance Error Scoring System (BESS), Brief Symptom Inventory-18 (BSI-18), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptom Scale (PCSS), Sport Concussion Assessment Tool-5th Edition (SCAT5), and Standardized Assessment of Concussion (SAC). There were 333 athletes with a history of diagnosed sleep disorders who were matched on age, sex, sport, and concussion history to 333 athletes with no history of diagnosed sleep disorders. Participants in both groups had a mean age of 19.89 ± 1.36 years and included 182 (54.7%) male athletes, and 126 (37.8%) reported a history of ≥1 concussions. A series of 1-way analyses of covariance with Bonferroni corrections revealed significant group differences on the BESS (F1,559 = 8.88; P < .01); BSI-18 somatization (F1,640 = 18.48; P < .01), depression (F1,640 = 18.78; P < .01), anxiety (F1,640 = 19.42; P < .01), and global severity index (F1,640 = 27.18; P < .01); PCSS (F1,424 = 29.42; P < .01); SCAT5 symptom number (F1,634 = 28.79; P < .01) and symptom severity (F1,634 = 31.74; P < .01); and SAC (F1,578 = 4.36; P = .037). Specifically, while the sleep disorder group did perform better on the BESS, they also reported higher symptoms on the BSI-18, PCSS, and SCAT5 and performed worse on the SAC. There were no group differences on ImPACT performance. Collegiate student-athletes with diagnosed sleep disorders reported elevated affective and concussion symptoms at baseline that could affect the interpretation of postinjury impairments and symptoms. Based on the small effect sizes of our findings, however, the magnitude of these differences is of questionable clinical significance. Still, clinicians should consider diagnosed sleep disorders as reported during preparticipation sports physical examinations when interpreting baseline and postinjury concussion assessments.


Unimolecular reaction chemistry of a charge-tagged beta-hydroxyperoxyl radical.
β-Hydroxyperoxyl radicals are formed during atmospheric oxidation of unsaturated volatile organic compounds such as isoprene. They are intermediates in the combustion of alcohols. In these environments the unimolecular isomerization and decomposition of β-hydroxyperoxyl radicals may be of importance, either through chemical or thermal activation. We have used ion-trap mass spectrometry to generate the distonic charge-tagged β-hydroxyalkyl radical anion, ˙CH2C(OH)(CH3)CH2C(O)O(-), and investigated its subsequent reaction with O2 in the gas phase under conditions that are devoid of complicating radical-radical reactions. Quantum chemical calculations and master equation/RRKM theory modeling are used to rationalize the results and discern a reaction mechanism. Reaction is found to proceed via initial hydrogen abstraction from the γ-methylene group and from the β-hydroxyl group, with both reaction channels eventually forming isobaric product ions due to loss of either ˙OH + HCHO or ˙OH + CO2. Isotope labeling studies confirm that a 1,5-hydrogen shift from the β-hydroxyl functionality results in a hydroperoxyalkoxyl radical intermediate that can undergo further unimolecular dissociations. Furthermore, this study confirms that the facile decomposition of β-hydroxyperoxyl radicals can yield ˙OH in the gas phase.


Extrasynaptic GABA(A) receptors and tonic inhibition in rat auditory thalamus.
Neural inhibition plays an important role in auditory processing and attentional gating. Extrasynaptic GABA(A) receptors (GABA(A)R), containing α(4)and δ GABA(A)R subunits, are thought to be activated by GABA spillover outside of the synapse following release resulting in a tonic inhibitory Cl(-) current which could account for up to 90% of total inhibition in visual and somatosensory thalamus. However, the presence of this unique type of inhibition has not been identified in auditory thalamus. The present study used gaboxadol, a partially selective potent agonist for δ-subunit containing GABA(A) receptor constructs to elucidate the presence of extrasynaptic GABA(A)Rs using both a quantitative receptor binding assay and patch-clamp electrophysiology in thalamic brain slices. Intense [(3)H]gaboxadol binding was found to be localized to the MGB while whole cell recordings from MGB neurons in the presence of gaboxadol demonstrated the expression of δ-subunit containing GABA(A)Rs capable of mediating a tonic inhibitory Cl(-) current. Potent tonic inhibitory GABA(A)R responses mediated by extrasynaptic receptors may be important in understanding how acoustic information is processed by auditory thalamic neurons as it ascends to auditory cortex. In addition to affecting cellular behavior and possibly neurotransmission, functional extrasynaptic δ-subunit containing GABA(A)Rs may represent a novel pharmacological target for the treatment of auditory pathologies including temporal processing disorders or tinnitus.


Liver Enzymes and Risk of Stroke: The Atherosclerosis Risk in Communities (ARIC) Study.
Liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], and gamma-glutamyl transpeptidase [GGT]) are glutamate-regulatory enzymes, and higher glutamate levels correlated with worse prognosis of patients with neurotrauma. However, less is known about the association between liver enzymes and incidence of stroke. We evaluated the association between serum levels of AST, ALT, and GGT and incidence of stroke in the Atherosclerosis Risk in Communities (ARIC) study cohort from 1990 to 1992 through December 31, 2016. We included 12,588 ARIC participants without prevalent stroke and with data on liver enzymes ALT, AST, and GGT at baseline. We used multivariable Cox regression models to examine the associations between liver enzymes levels at baseline and stroke risk (overall, ischemic stroke, and intracerebral hemorrhage [ICH]) through December 31, 2016, adjusting for potential confounders. During a median follow-up time of 24.2 years, we observed 1,012 incident strokes (922ischemic strokes and 90 ICH). In age, sex, and race-center adjusted models, the hazard ratios (HRs; 95% confidence intervals [CIs]) for the highest compared to lowest GGT quartile were 1.94 (95% CI, 1.64 to 2.30) for all incident stroke and 2.01 (95% CI, 1.68 to 2.41) for ischemic stroke, with the results supporting a dose-response association (P for linear trend <0.001). Levels of AST were associated with increased risk of ICH, but the association was significant only when comparing the third quartile with the lowest quartile (adjusted HR, 1.82; 95% CI, 1.06 to 3.13). Elevated levels of GGT (within normal levels), independent of liver disease, are associated with higher risk of incident stroke overall and ischemic stroke, but not ICH.


Differential activation of the amygdala and the 'social brain' during fearful face-processing in Asperger Syndrome.
Impaired social cognition is a core feature of autism. There is much evidence showing people with autism use a different cognitive style than controls for face-processing. We tested if people with autism would show differential activation of social brain areas during a face-processing task. Thirteen adults with high-functioning autism or Asperger Syndrome (HFA/AS) and 13 matched controls. We used fMRI to investigate 'social brain' activity during perception of fearful faces. We employed stimuli known to reliably activate the amygdala and other social brain areas, and ROI analyses to investigate brain areas responding to facial threat as well as those showing a linear response to varying threat intensities. We predicted: (1) the HFA/AS group would show differential activation (as opposed to merely deficits) of the social brain compared to controls and (2) that social brain areas would respond to varied intensity of fear in the control group, but not the HFA/AS group. Both predictions were confirmed. The controls showed greater activation in the left amygdala and left orbito-frontal cortex, while the HFA/AS group showed greater activation in the anterior cingulate gyrus and superior temporal cortex. The control group also showed varying responses in social brain areas to varying intensities of fearful expression, including differential activations in the left and right amygdala. This response in the social brain was absent in the HFA/AS group. HFA/AS are associated with different patterns of activation of social brain areas during fearful emotion processing, and the absence in the HFA/AS brain of a response to varying emotional intensity.


Taxanes: vesicants, irritants, or just irritating?
Several classes of antineoplastic agents are universally referred to as vesicants with ample supporting literature. However, the literature surrounding the taxanes is controversial. While the American Society of Clinical Oncology and Oncology Nursing Society Chemotherapy Administration Safety Standards and the Chemotherapy and Biotherapy Guidelines and Recommendations for Practice identify the risks of extravasation and the parameters surrounding the infusion of known vesicants, recommend administration sites for known agents, and recommend antidotes for particular extravasation cases, they fail to provide specific recommendations for the administration of individual taxanes, or a classification system for antineoplastic agents as vesicants, irritants, or inert compounds. There is also a lack of prescribing information regarding such recommendations. The lack of a formal classification system further complicates the accurate delineation of vesicant antineoplastic agents and subsequent appropriate intravenous administration and extravasation management. There are several factors that make the classification of taxanes as vesicants or irritants challenging. Comprehensive preclinical data describing potential mechanisms of tissue damage or vesicant-like properties are lacking. Furthermore, most case reports of taxane extravasation fail to include the parameters surrounding administration, such as the concentration of medication and duration of infusion, making it difficult to set parameters for vesicant potential. Subsequently, many practitioners default to central venous administration of taxanes without evidence that such administration minimizes the risk of extravasation or improves outcomes thereof. Here, we review briefly the data surrounding taxane extravasation and potential vesicant or irritant properties, classify the taxanes, and propose a spectrum for antineoplastic agent potential to cause tissue injury that warrants clinical intervention if extravasation occurs.


Osler Centenary Papers: Would Sir William Osler be a role model for medical trainees and physicians today?
If Sir William Osler were alive and practising as one of our contemporary colleagues, would he be viewed as a role model by medical trainees and other physicians? Recently published literature has sought to define clinical excellence; this characterisation of physician performance establishes a context in which role models in medicine can be appraised. Building on this framework, we present rich anecdotes and quotes from Sir William Osler himself, his colleagues, and his students to consider whether Osler would have been regarded as a role model for clinical excellence today. This paper illustrates convincingly that William Osler indeed personified clinical excellence and would have been appreciated as a consummate role model if he were alive and on a medical school's faculty today. However, a century has passed since his death, and he is not sufficiently visible today to serve as a role model to modern medical trainees and physicians. Moreover, we speculate that Osler himself would not have wanted to be a role model for today's trainees, as he emphasised that medicine is best learned from teachers at the bedside-a place where he cannot be. Reanimating Osler through rich stories and inspiring quotes, and translating his example of clinical excellence into modern clinical practice, can remind us all to carry Oslerian virtues with us in our professional work.


Submucous Cleft Palate: A Systematic Review of Surgical Management Based on Perceptual and Instrumental Analysis.
Objective: Submucous cleft palate (SMCP) is a congenital condition associated with abnormal development of the soft palate musculature. In a proportion of cases, this results in velopharyngeal insufficiency (VPI), the treatment for which includes pharyngeal flap surgery, pharyngoplasty, and palate reconstruction. The aim of this paper is to determine whether there is superiority of one or more types of surgical procedure over the others in improving speech in patients with VPI secondary to SMCP. Methodology: Nine databases, including MEDLINE and EMBASE, were searched between inception and January 2013 to identify articles published relating to the surgical management of SMCP. Only studies that reported outcome measures for postoperative speech were included in the systematic review. Results: Twenty-six studies analyzing the outcomes of surgery for VPI in patients with SMCP met the inclusion criteria. In these studies, speech outcomes were measured either in a binary fashion (i.e., normal speech or evidence of VPI) or using scales of VPI severity. Of the 26 studies, only two utilized blinded speech assessment, and 12 included both preoperative and postoperative speech assessment. Conclusions: The review found little evidence to support any specific surgical intervention. This is in large part due to the inclusion of mixed etiologies within study populations and the lack of unbiased validated preoperative and postoperative speech assessment. Further methodologically rigorous studies need to be conducted to provide a secure evidence base for the surgical management of SMCP.


Secondary prevention after coronary artery bypass grafting--what do we know?
There is insufficient knowledge about secondary prevention after coronary artery bypass grafting (CABG). Most of it is gathered from patients suffering from myocardial infarction and angina pectoris, only a minority of whom have undergone CABG. Whereas it seems clear that these patients should give up smoking and reduce low-density lipoprotein (LDL) cholesterol, there is uncertainty about the optimal antiplatelet regimen and antithrombotic treatment. There are some data indicating the benefit of behaviour modification. There is room for improvement and more knowledge when it comes to secondary prevention after CABG.


Efficient and specific repair of sickle beta-globin RNA by trans-splicing ribozymes.
Previously we demonstrated that a group I ribozyme can perform trans-splicing to repair sickle beta-globin transcripts upon transfection of in vitro transcribed ribozyme into mammalian cells. Here, we sought to develop expression cassettes that would yield high levels of active ribozyme after gene transfer. Our initial expression constructs were designed to generate trans-slicing ribozymes identical to those used in our previous RNA transfection studies with ribozymes containing 6-nucleotide long internal guide sequences. The ribozymes expressed from these cassettes, however, were found to be unable to repair sickle beta-globin RNAs. Further experiments revealed that two additional structural elements are important for ribozyme-mediate RNA repair: the P10 interaction formed between the 5' end of the ribozyme and the beginning of the 3' exon and an additional base-pairing interaction formed between an extended guide sequence and the substrate RNA. These optimized expression cassettes yield ribozymes that are able to amend 10%-50% of the sickle beta-globin RNAs in transfected mammalian cells. Finally, a ribozyme with a 5-bp extended guide sequence preferentially reacts with sickle beta-globin RNAs over wild-type beta-globin RNAs, although the wild-type beta-globin transcript forms only a single mismatch with the ribozyme. These results demonstrate that trans-splicing ribozyme expression cassettes can be generated to yield ribozymes that can repair a clinically relevant fraction of sickle beta-globin RNAs in mammalian cells with greatly improved specificity.


Soil dust aerosols and wind as predictors of seasonal meningitis incidence in Niger.
Epidemics of meningococcal meningitis are concentrated in sub-Saharan Africa during the dry season, a period when the region is affected by the Harmattan, a dry and dusty northeasterly trade wind blowing from the Sahara into the Gulf of Guinea. We examined the potential of climate-based statistical forecasting models to predict seasonal incidence of meningitis in Niger at both the national and district levels. We used time series of meningitis incidence from 1986 through 2006 for 38 districts in Niger. We tested models based on data that would be readily available in an operational framework, such as climate and dust, population, and the incidence of early cases before the onset of the meningitis season in January-May. Incidence was used as a proxy for immunological state, susceptibility, and carriage in the population. We compared a range of negative binomial generalized linear models fitted to the meningitis data. At the national level, a model using early incidence in December and averaged November-December zonal wind provided the best fit (pseudo-R2 = 0.57), with zonal wind having the greatest impact. A model with surface dust concentration as a predictive variable performed indistinguishably well. At the district level, the best spatiotemporal model included zonal wind, dust concentration, early incidence in December, and population density (pseudo-R2 = 0.41). We showed that wind and dust information and incidence in the early dry season predict part of the year-to-year variability of the seasonal incidence of meningitis at both national and district levels in Niger. Models of this form could provide an early-season alert that wind, dust, and other conditions are potentially conducive to an epidemic.


CLIPB4 is a central node in the protease network that regulates humoral immunity in Anopheles gambiae mosquitoes.
Insect humoral immune responses are regulated in part by protease cascades, whose components circulate as zymogens in the hemolymph. In mosquitoes, these cascades consist of clip domain serine proteases (cSPs) and/or their non-catalytic homologs (cSPHs), which form a complex network, whose molecular make-up is not fully understood. Using a systems biology approach, based on a co-expression network of gene family members that function in melanization and co-immunoprecipitation using the serine protease inhibitor (SRPN)2, a key negative regulator of the melanization response in mosquitoes, we identify the cSP CLIPB4 from the African malaria mosquito Anopheles gambiae as a central node in this protease network. CLIPB4 is tightly co-expressed with SRPN2 and forms protein complexes with SRPN2 in the hemolymph of immune-challenged female mosquitoes. Genetic and biochemical approaches validate our network analysis and show that CLIPB4 is required for melanization and antibacterial immunity, acting as a prophenoloxidase (proPO)-activating protease, which is inhibited by SRPN2. In addition, we provide novel insight into the structural organization of the cSP network in An. gambiae, by demonstrating that CLIPB4 is able to activate proCLIPB8, a cSP upstream of the proPO-activating protease CLIPB9. These data provide the first evidence that, in mosquitoes, cSPs provide branching points in immune protease networks and deliver positive reinforcement in proPO activation cascades.


Angiographic follow-up of large cerebral AVMs incompletely embolized with isobutyl-2-cyanoacrylate.
This study evaluated the long-term angiographic results in large cerebral arteriovenous malformations (AVMs) partially embolized with isobutyl-2-cyanoacrylate. Preembolization, immediate postembolization, and long-term follow-up angiograms were performed in 30 large, partially embolized brain AVMs. Particular attention was paid to the relative size of the residual AVM nidus and the embolized arterial feeders, to recruitment of new feeders, to the size of residual draining veins, and to the speed of arteriovenous shunt. Nine cases with less than 50% AVM nidus obliteration showed no significant morphologic changes. In 18 cases with 50-75% obliteration of the AVM nidus, 11 (61.1%) showed no significant changes, six (33.3%) showed enlargement of the AVM nidus, and one (5.5%) evolved to complete angiographic obliteration. In three cases with 75-99% AVM nidus obliteration, one remained unchanged, one showed an increase in the size of the AVM nidus, and one evolved to complete obliteration. Evaluation by plain film, CT, and cerebral angiography of the isobutyl-2-cyanoacrylate deposits showed that when the polymer was positioned predominantly in arterial feeders there was invariably reconstitution of the AVM nidus through leptomeningeal, deep medullary, and/or dural collaterals. This phenomenon did not occur when the isobutyl-2-cyanoacrylate was deposited mainly in the AVM nidus.


Erythrocyte membrane changes of chorea-acanthocytosis are the result of altered Lyn kinase activity.
Acanthocytic RBCs are a peculiar diagnostic feature of chorea-acanthocytosis (ChAc), a rare autosomal recessive neurodegenerative disorder. Although recent years have witnessed some progress in the molecular characterization of ChAc, the mechanism(s) responsible for generation of acanthocytes in ChAc is largely unknown. As the membrane protein composition of ChAc RBCs is similar to that of normal RBCs, we evaluated the tyrosine (Tyr)-phosphorylation profile of RBCs using comparative proteomics. Increased Tyr phosphorylation state of several membrane proteins, including band 3, β-spectrin, and adducin, was noted in ChAc RBCs. In particular, band 3 was highly phosphorylated on the Tyr-904 residue, a functional target of Lyn, but not on Tyr-8, a functional target of Syk. In ChAc RBCs, band 3 Tyr phosphorylation by Lyn was independent of the canonical Syk-mediated pathway. The ChAc-associated alterations in RBC membrane protein organization appear to be the result of increased Tyr phosphorylation leading to altered linkage of band 3 to the junctional complexes involved in anchoring the membrane to the cytoskeleton as supported by coimmunoprecipitation of β-adducin with band 3 only in ChAc RBC-membrane treated with the Lyn-inhibitor PP2. We propose this altered association between membrane skeleton and membrane proteins as novel mechanism in the generation of acanthocytes in ChAc.


Joints for joints: cannabinoids in the treatment of rheumatoid arthritis.
An increasing number of patients with rheumatoid arthritis (RA) are using cannabis to treat their symptoms, although systematic studies regarding efficacy in RA are lacking. Within this review we will give an overview on the overall effects of cannabinoids in inflammation and why they might be useful in the treatment of RA. Peripherally, cannabinoids show anti-inflammatory effects by activating cannabinoid type 2 receptors (CB2) which decrease cytokine production and immune cell mobilization. In contrast, cannabinoid type 1 receptor (CB1) activation on immune cells is proinflammatory while CB1 antagonism provides anti-inflammatory effects by increasing β2-adrenergic signaling in the joint and secondary lymphoid organs. In addition, the nonpsychotropic cannabinoid, cannabidiol (CBD) demonstrated antiarthritic effects independent of cannabinoid receptors. In addition to controlling inflammation, cannabinoids reduce pain by activating central and peripheral CB1, peripheral CB2 receptors and CBD-sensitive noncannabinoid receptor targets. Cannabinoids might be a suitable treatment for RA, but it is important to target the right receptors in the right place. For clinical studies, we propose a combination of a CB2 agonist to decrease cytokine production, a peripheral CB1 antagonist to prevent detrimental CB1 signaling and to support anti-inflammatory effects of CB2 via activation of β2-adrenergic receptors and CBD to induce cannabinoid-receptor-independent anti-inflammatory effects.


How do clinicians manage vaginal complaints? An Internet survey.
Although vaginal symptoms are among the most common presentations in primary care, little is known about how clinicians manage them. We undertook an Internet survey to determine how clinicians decided what was normal, how they evaluated vaginal complaints, and what happened when a diagnosis could not be reached. A 27-question anonymous survey was conducted using the Medscape Internet publication platform and Medscape General Medicine , an online, peer-reviewed, open-access general medical journal. The study was targeted at physicians and nurse practitioners. There were 556 nurse practitioner and 608 physician respondents. Clinicians generally agreed that a midcycle increase in discharge and discharge seen at the introitus were normal; itching/irritation, odor, and a green discharge were not. There was less agreement concerning the value of a yellow discharge and "self-diagnosis" of abnormality. Eighty-two percent of MDs and 77% of NPs reported examining patients prior to treatment always or often. Only about 30% performed pH testing always or often. Ninety percent of NPs and 92% of MDs reported not making a diagnosis rarely or sometimes. When offered 4 different management strategies for patients in whom no diagnosis was made (watch and wait, symptomatic therapy, empiric antibiotics, referral), there was no clear preference. There was a weak correlation between performance of a wet mount and reports of less non-diagnosis. There was no correlation between pH and whiff testing and reports of less non-diagnosis. Clinicians do not always agree about what constitutes a vaginal symptom. Although most providers usually examine patients with vaginal complaints, pH and whiff testing are performed less frequently. Our data suggest the latter 2 maneuvers are not diagnostically helpful. There is no consensus regarding what to do when no diagnosis is made. Our findings suggest that the traditional approach to the evaluation of vaginal symptoms may have limited relevance for clinicians.


Pathogenicity and transmission in pigs of the novel A(H3N2)v influenza virus isolated from humans and characterization of swine H3N2 viruses isolated in 2010-2011.
Swine influenza virus (SIV) H3N2 with triple reassorted internal genes (TRIG) has been enzootic in Unites States since 1998. Transmission of the 2009 pandemic H1N1 (pH1N1) virus to pigs in the United States was followed by reassortment with endemic SIV, resulting in reassorted viruses that include novel H3N2 genotypes (rH3N2p). Between July and December 2011, 12 cases of human infections with swine-lineage H3N2 viruses containing the pandemic matrix (pM) gene [A(H3N2)v] were detected. Whole-genome analysis of H3N2 viruses isolated from pigs from 2009 to 2011 sequenced in this study and other available H3N2 sequences showed six different rH3N2p genotypes present in the U.S. swine population since 2009. The presence of the pM gene was a common feature among all rH3N2p genotypes, but no specific genotype appeared to predominate in the swine population. We compared the pathogenic, transmission, genetic, and antigenic properties of a human A(H3N2)v isolate and two swine H3N2 isolates, H3N2-TRIG and rH3N2p. Our in vivo study detected no increased virulence in A(H3N2)v or rH3N2p viruses compared to endemic H3N2-TRIG virus. Antibodies to cluster IV H3N2-TRIG and rH3N2p viruses had reduced cross-reactivity to A(H3N2)v compared to other cluster IV H3N2-TRIG and rH3N2p viruses. Genetic analysis of the hemagglutinin gene indicated that although rH3N2p and A(H3N2)v are related to cluster IV of H3N2-TRIG, some recent rH3N2p isolates appeared to be forming a separate cluster along with the human isolates of A(H3N2)v. Continued monitoring of these H3N2 viruses is necessary to evaluate the evolution and potential loss of population immunity in swine and humans.


Psychosocial distress associated with treatment of hypertensive diseases in pregnancy.
Hypertensive diseases in pregnancy (HDP) are a great challenge for healthcare providers. The study aimed to investigate the experience of women developing HDP with different stressors associated with healthcare after a diagnosis of HDP. A self- administered questionnaire referring to stress associated with general aspects, hospital stay, and mode of delivery was given to a convenience sample of 738 women with one pregnancy complicated by HDP. The three main aspects causing stress after diagnosis of HDP were the duration of hospital stay for women having to stay at least 7 days in the hospital, the infant's prematurity, and uncertainty about the child's health. Most stress factors did not vary among women showing different types of HDP, but with infants' gestational age at delivery. The diagnosis of HDP leads to important stress during pregnancy. In addition to stressors caused by other obstetrical complications, women developing HDP have to deal with a sudden and dramatic change in fetal health risk as well as their own sometimes life-threatening situation. Because stress may have an unfavorable effect on the clinical course of the disease, these aspects should be considered when treating women with HDP.


Oncogene ablation-resistant pancreatic cancer cells depend on mitochondrial function.
Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers in western countries, with a median survival of 6 months and an extremely low percentage of long-term surviving patients. KRAS mutations are known to be a driver event of PDAC, but targeting mutant KRAS has proved challenging. Targeting oncogene-driven signalling pathways is a clinically validated approach for several devastating diseases. Still, despite marked tumour shrinkage, the frequency of relapse indicates that a fraction of tumour cells survives shut down of oncogenic signalling. Here we explore the role of mutant KRAS in PDAC maintenance using a recently developed inducible mouse model of mutated Kras (Kras(G12D), herein KRas) in a p53(LoxP/WT) background. We demonstrate that a subpopulation of dormant tumour cells surviving oncogene ablation (surviving cells) and responsible for tumour relapse has features of cancer stem cells and relies on oxidative phosphorylation for survival. Transcriptomic and metabolic analyses of surviving cells reveal prominent expression of genes governing mitochondrial function, autophagy and lysosome activity, as well as a strong reliance on mitochondrial respiration and a decreased dependence on glycolysis for cellular energetics. Accordingly, surviving cells show high sensitivity to oxidative phosphorylation inhibitors, which can inhibit tumour recurrence. Our integrated analyses illuminate a therapeutic strategy of combined targeting of the KRAS pathway and mitochondrial respiration to manage pancreatic cancer.


Spinal Pleomorphic Xanthoastrocytoma With a QKI-RAF1 Fusion.
Pleomorphic xanthoastrocytoma (PXA) is a slow-growing neoplasm that predominantly affects the pediatric and young adult population. This neoplasm has a good prognosis, with a median 10-year survival rate of 70%. The majority of tumors are supratentorial and arise in the temporal lobe, while spinal tumors are extremely rare, with only 8 reported cases. Molecular perturbations involving the MAPK/ERK signaling pathway have been described in PXAs. The most common mutation is BRAF V600E in 60%-80% of cases. Other mechanisms activating this pathway in the absence of this mutation are rare and include CRAF (RAF1) fusion genes. We report a PXA case in the cervical spinal cord of a 49-year-old man with slowly progressive coordination difficulties and extremity numbness. The tumor was negative for the V600E mutation, but 2 RNA sequencing platforms detected a QKI-RAF1 fusion (t(6; 3)(q26; p25)), which has not been previously reported in PXAs. This fusion is known to activate MAPK/ERK and PI3K/mTOR signaling. Although first- and second-generation RAF inhibitors are predicted to be ineffective, this fusion may be targetable by the novel RAF inhibitor LY3009120 and to some extent by the MEK inhibitor trametinib. Genetic analysis to screen for MAPK/ERK pathway mutations is warranted on PXAs negative for the V600E mutation.